Medicare Compliance & Reimbursement

Review the requirements of MWVs and AWVs.

Regular checkups for patients is a given in any general physician (GP) practice. In this issue, we delve into the differences between adult preventive visits and Medicare Wellness Visits (MWVs).

Read on for helpful information about these differences as explained by Christine Hall, CHC, CDEO, CPC, CPB, CPMA, CRC, CEMC, CPC-I, CEO and senior consultant at Stirling Global Solutions LLC, in her HEALTHCON 2024 presentation, “An Ounce of Prevention is Worth a Pound of Cure.” You’ll also find a few common screenings that may apply to both.

Understand the Purpose of Under-65 Preventive Visits …

Purpose: These visits feature an exam performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury, including laboratory and diagnostic procedures. They are typically covered by commercial payers, Medicaid, and many Medicare Advantage plans. They are billed based on new versus established patient status and patient age.

Coding: To code preventive visits, you’ll turn to 99381 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)) through 99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/ diagnostic procedures, established patient; 65 years and older)

… And How it Differs from the Purpose of Medicare Wellness Visits

Purpose: These visits help prevent disease and disability for future medical issues based on the beneficiary’s health and risk factors as indicated by a series of tools (e.g., health risk assessment). They are covered by both Medicare and Medicare Advantage plans and, in the case of at least one code, billed based on the Medicare Part B effective date.

Coding: To code Medicare wellness visits, you’ll use G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment), G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit), or G0439 (… subsequent visit).

Critical: It’s important to remember that the title “Medicare Wellness Visit” (MWV) is a colloquial term that encompasses three different types of visit, according to the Centers for Medicare & Medicaid Services (CMS). Though MWV might be used to refer to a specific exam in a clinical setting and by coders, Medicare doesn’t see it that way — and that’s where confusion sets in. CMS lists its “Welcome to Medicare Visit,” also knows as the Initial Preventive Physical Exam (IPPE) (code G0402), the Annual Wellness Visit (AWV) both initial (G0438) and subsequent (G0439), and routine physical exams under the umbrella of MWVs, the agency notes in the MLN release “Medicare Wellness Visits.”

Additionally, IPPEs and AWVs — due to the typical Medicare billing nuances associated with them — are perennial audit favorites and sit atop Recover Audit Contractors’ (RACs), Targeted Probe and Educate (TPE) reviewers’, and Comprehensive Error Rate Testing (CERT) auditors’ to-do lists.

Realize the Role of the Physical Exam

Patients don’t always understand the differences between standard adult preventive services and the MWV/AWV, and the same often goes for coders. There is often an inherent expectation attached to annual visits of all kinds, which can lead to confusion when a physical exam is either not performed or not covered by the payer. Here’s a breakdown of how physical exams play into each kind of visit:

Preventive: A physical exam for an adult is an age- and gender-appropriate comprehensive exam where the healthcare provider checks the patient’s overall health. This is an assessment of the patient’s general health, helps identify any potential health issues, and offers an opportunity for the doctor to provide anticipatory medical advice, counseling, or risk reduction.

MWV/AWV: The IPPE is a physical exam, which Medicare covers, but “it’s the only covered preventive physical exam that a traditional Medicare beneficiary receives as they enter the Medicare program. Within that first 12 months, we need to get a good picture of what the patient looks like,” said Hall. It’s important to note that the patient will not get an annual physical exam yearly after that. “After that first year, they’re eligible for an initial annual wellness visit, not a physical exam, Hall continued.

Understand the Parts of the MWV and AWV

There are distinct components that the provider must fulfill and, therefore, be documented to bill for MWVs. Most of the components are the same for IPPE and AWV, although they are described differently in some cases. Common components include:

1. A review of the patient’s medical and social history
2. A review of the patient’s potential risk factors for depression and other mood disorders
3. A review of the patient’s functional ability and safety level, which may encompass daily activities, fall risk, and home safety evaluation
4. Measurement of vital signs, including blood pressure, height, weight, and body mass index (BMI) (or waist circumference, if appropriate). The IPPE also includes a visual acuity screen on this list.
5. Review of current opioid prescriptions
6. Screen for potential substance use disorders
7. A personalized prevention plan that includes a written schedule for preventive services and referral for appropriate preventive services, such as screenings, immunizations, etc.
8. Establish a list of risk factors and conditions for which the patient needs primary, secondary, or tertiary intervention
9. Documentation of the patient’s advance care planning status or the provision of resources to assist with advance care planning, at the patient’s discretion

AWVs includes up to four additional components:

1. Perform a health risk assessment
2. Establish current providers and suppliers list
3. Detect any cognitive impairment patients may have
4. Perform an optional social determinants of health risk assessment (new in 2024)

See Where Preventive Medicine and MWV/AWV Services Overlap

While there may be certain criteria to meet per the payer’s plan, there are some screenings and tests that may apply to adults under and over age 65. Here are a few along with their corresponding codes: